- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,398.83 / $3,235.94 / $3,981.07
| Facility | | $2,398.83 | $3,235.94 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.81 / $588.84 / $1,584.89
| Professional | | $524.81 | $588.84 | $1,584.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.81 / $602.56 / $977.24
| Professional | | $524.81 | $602.56 | $977.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $660.69 / $794.33 / $1,230.27
| Professional | | $660.69 | $794.33 | $1,230.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,570.40 / $4,570.88 / $7,585.78
| Facility | | $2,570.40 | $4,570.88 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $691.83 / $1,288.25
| Professional | | $501.19 | $691.83 | $1,288.25 |